Comparação entre dois dispositivos supraglóticos de vias aéreas na dor de garganta pós‐operatória em crianças: estudo controlado prospectivo randomizado

Background and objectiveSore throat is well recognized complaint after receiving general anesthesia. This study is conducted to compare the severity and frequency of postoperative sore throat in children undergoing elective surgery – following the use of Ambu laryngeal mask airway) or I‐gel® – who are able to self‐report postoperative sore throat.MethodSeventy children, 6 to 16 years‐old, undergoing elective surgery randomly allocated to either Ambu laryngeal mask (Ambu Group) or I‐gel® (I‐gel Group). After the procedure, patients were interviewed in the recovery room immediately, after one hour, 6 and 24 hours postoperatively by an independent observer blinded to the device used intra‐operatively.ResultsOn arrival in the recovery room 17.1% (n = 6) of children of the Ambu Group complained of postoperative sore throat, against 5.7% in I‐gel Group (n = 2). After one hour, the results were similar. After 6 hours, postoperative sore throat was found in 8.6% (n = 3) of the children in Ambu group vs. 2.9% (n = 1) in I‐gel Group. After 24 hours, 2.9% (n = 1) of the kids in Ambu Group compared to none in I‐gel Group. There was no significant difference found in the incidence of postoperative sore throat in both devices on arrival (p = 0.28); after 1 hour (p = 0.28); after 6 hours (p = 0.30); and after 24 hours (p = 0.31). The duration of the insertion was shorter in Ambu Group and it was easier to insert the I‐gel® (p = 0.029). Oropharyngeal seal pressure of I‐gel® was higher than that of Ambu laryngeal mask (p = 0.001).ConclusionThe severity and frequency of postoperative sore throat in children is not statistically significant in the I‐gel Group compared to Ambu Group.     

Embolización vesical supraselectiva versus formalina intravesical para la hematuria intratable en pacientes con cáncer de vejiga

ObjectiveIntractable hematuria is a leading critical problem occurring in patients with advanced stage bladder cancer (BCa) that are not suitable for radical cystectomy. The present study, for the first time in the literature, aimed to compare the effectiveness of intravesical formalin (IF) and superselective vesical artery embolization (SVAE) in the management of intractable and life-threatening hematuria in BCa patients.MethodsThe retrospective study included 40 BCa patients who underwent SVAE or IF treatment due to intractable hematuria after failure of other methods. Patients were divided into two groups based on the procedures administered: SVEA Group (n = 24) and IF Group (n = 16).ResultsThe success rate at first-line therapy was 50% (12/24) in SVAE Group and 82% (13/16) in IF Group (p = 0.046). Based on the success rates at first- and second-line therapies, the overall success rate in SVAE Group was 75% and this rate was similar to that of IF Group (p = 0.439). Complication rate was significantly higher in IF patients than in SVAE patients (37.5% vs. 8.3; p = 0.024), whereas duration of postoperative hospital stay was significantly longer in SVAE Group (15.8 vs. 6 days; p = 0.041).ConclusionThe advantages of IF appear to include shorter postoperative hospital stays and higher success rates at a single session, while the advantages of SVAE seem to include non-requirement of spinal/general anesthesia, easy repeatability, and low complication rates. In the management of patients with intractable hematuria, patients’ general condition, comorbidities, and anesthesia-related risks should be taken into consideration.     

Treatment of shoulder calcifications of the cuff: A controlled study

ObjectivesAbout 1 in 10 patients with shoulder calcifications complains of chronic pain. Removal techniques have been developed. We carried out the first randomized study to validate bursoscopy (BS) and (needling fragmentation irrigation) (NFI) versus a control group (CT).Methods102 shoulders (96 patients) with calcifications >5 mm whose medical treatment had failed (>4 months) were first injected using a corticosteroid; 49 shoulders improved by more than 70%. The other 53 shoulders were randomized in 3 groups: NFI (n = 16), BS (n = 20), and CT (n = 17). All patients were reviewed at T 1–4–12–24 months.ResultsAfter 4 months, we observed respectively in groups NFI – BS – CT: 62%, 65% and 29% patients showing global improvements >70% (NFI vs CT: p = 0.03; BS vs CT: p = 0.02); ?37%, ?29% and ?11% pain VAS variation (ns), +16%, +12% and ?15% Constant score variation (NFI vs CT: p = 0.03; BS vs CT: p = 0.02), and ?58%, ?77% and +4% area calcification variation (NFI vs CT: p = 0.005; BS vs CT: p = 0.0002; BS vs NFI: p = 0.01). After 24 months, results were maintained in NFI and BS groups, and in the CT group only 6/17 patients were still improved. There were no significant differences between NFI and BS groups. Three partial tears of the cuff were found using MRI in failures, (1 in each group).ConclusionNFI and BS are now validated removal techniques of shoulder calcifications when there is chronic pain and other medical treatments have failed. Results were maintained after 24 months, and were similar between NFI and BS. However NFI could be preferred because of its simplicity and low cost.     

Short-Term Results of A Randomized Trial Comparing Remote Endarterectomy and Supragenicular Bypass Surgery for Long Occlusions of the Superficial Femoral Artery [The REVAS Trial]

ObjectiveTechniques for surgical repair of Trans-Atlantic Inter-Society Consensus (TASC) C and D lesions of the superficial femoral artery (SFA) are supragenicular bypass grafting or the less invasive remote endarterectomy (RSFAE). This trial compares the patency rates of both techniques.DesignRandomized, multicenter trial.Materials and methods116 patients were randomized to RSFAE (n = 61) and supragenicular bypass surgery (n = 55). Indications for surgery were claudication (n = 77), rest pain (n = 21), or tissue loss (n = 18).ResultsMedian hospital stay was 4 days in the RSFAE group compared with 6 days in the bypass group (p = 0.004). Primary patency after 1-year follow-up was 61% for RSFAE and 73% for bypass (p = 0.094). Secondary patency was 79% for both groups. Subdividing between venous (n = 25) and prosthetic grafts (n = 30) shows a primary patency of 89% and 63% respectively at 1-year follow-up (p = 0.086).ConclusionRSFAE is a minimally invasive adjunct in the treatment of TASC C and D lesions of the SFA, with shorter admittance and a comparable secondary patency rate to bypass. The venous bypass is superior to both RSFAE and PTFE bypass surgery, but only 45% of patients had a sufficient saphenous vein available.This study is registered with ClinicalTrials.gov, number NCT00566436.     

Transplacental transfer and neonatal influences of sonophoretically administered sufentanil versus epidural sufentanil in labor peridural analgesia: A randomized prospective double-blind contemplate

BackgroundLabor sufentanil impact on the newborn is debatable. This randomized double-blind investigation examined the transplacental conveyance and neonatal influences of sonophoretic versus epidural sufentanil for labor analgesia and its outcome on breast-feeding.Methods60 Healthy parturient women receiving labor epidural analgesia were enrolled in the study. They were administered epidural bupivacaine (12-ml bolus then 10 ml/h of 0.125%) solely (Group I, n = 20) or with sonophoretically transdermally administered sufentanil (Group II, n = 20) or with epidurally administered sufentanil (Group III, n = 20). Sufentanil received by Groups II and III was 15 μm followed by 10 ml/h of 0.25 μm/ml solution.ResultsSufentanil was detected in five umbilical arterial (UA) samples in Group III versus in two UA samples in Group II. Neonatal Neurologic and Adaptive Capacity Score (NACS) at 24 h was lowest in Group III (P = 0.04). On postpartum day 1, Group III women reported breast-feeding difficultly (25%) more oftentimes than Group II women (10%), or Group I women (5%) (P = 0.05). There was 45% breast-feeding difficulty in each group according to lactation consultant’s assessment (P = 1.0). At 6 weeks postpartum, more Group III women were not breast-feeding (35%) than Group II women (10%) or Group I (10%) (P = 0.004).ConclusionSufentanil transplacental transport and fetal exposure appeared greater in epidural than in sonophoretic sufentanil. The former group women were facing more difficulty at starting breast-feeding on postpartum day 1 and were more apt to have stopped breast-feeding 6 weeks postpartum than the latter group women.     

Treadmill versus overground gait training in patients with lower limb burn injury: A matched control study

IntroductionGait impairment is commonly seen in patients with a lower limb burn injury (LLBI). Therefore, the aim of this study was to investigate the effects of two different gait training modes on gait symmetry, functional mobility and kinesiophobia in patients with LLBI.MethodsThis matched control study was conducted between January 2017 and August 2018. Patients with LLBI (n = 28) were allocated to 2 different groups by matching according to burn localization, age, and gender. Group 1 (overground group: n = 14) received overground gait training in addition to standard burn rehabilitation, and Group 2 (treadmill group: n = 14) received treadmill gait training in addition to standard burn rehabilitation. The rehabilitation program and gait training were started when the patient was admitted to the hospital and ended on discharge. These physical therapy interventions were performed 5 days per week. The gait training intensity, including walking speed and duration, was determined according to patient tolerance. Gait parameters, functional mobility, kinesiophobia and pain values were evaluated with GAITRite, the timed up-and-go test (TUG), Tampa Kinesiophobia Scale and Visual Analogue Scale, respectively. These evaluations were made twice; on admission and immediately prior to discharge. Gait symmetry was calculated using the Symmetry Index.ResultsThe baseline characteristics of the groups and initial outcome values were similar. In the comparison of the differences between the overground and treadmill groups, the change in kinesiophobia and TUG values were significantly higher in the treadmill group (p = 0.01, p = 0.02, respectively). The intragroup comparisons showed significant differences in SI in respect of step length (p = 0.004), swing (p = 0.006), stance (p = 0.008) and velocity (p = 0.001), cadence (p = 0.001), TUG (p = 0.001), kinesiophobia (p = 0.001) and pain (p = 0.001) in the overground group. Statistically significant differences were determined in step length (p = 0.01), swing (p = 0.01), stance (p = 0.02) and velocity (p = 0.001), cadence (p = 0.001), TUG (p = 0.001), kinesiophobia (p = 0.001) and pain (p = 0.001) in the treadmill group, when pre and post-training values were compared.ConclusionsThe results of this study have shown that treadmill gait training was more effective in the improvement of functional mobility and reduction in kinesiophobia levels of patients with LLBI compared to overground gait training. Both overground and treadmill gait training also provide greater improvements in the velocity and cadence, and gait symmetry for step length, swing and stance in patients with LLBI.Clinical trial registration numberNCT03217526.     

Efeitos da musicoterapia sobre dor e estresse oxidativo na aspiração folicular: estudo clínico randomizado

Background and objectiveThe aim was to investigate the effects of Turkish classical music on pain and oxidative stress in patients undergoing oocyte pick‐up.MethodsThe study was a randomized, controlled trial. The groups included were Group NM (Non‐Music), control group; Group PM, which comprised patients who listened to music before the operation; and Group CM, which comprised patients who listened to music both before and during the operation. Blood was drawn prior to the operation to measure the oxidative stress values. Pain, hemodynamic parameters, oxidative stress values were assessed postoperatively.ResultsThe number of patients requiring additional propofol was higher in Group PM than in Groups NM and CM (p = 0.003). The postoperative Visual Analog Scale (VAS) score were lower in Groups PM and CM than in Group NM (p = 0.001, p = 0.007) in the 1^st and 60^th minutes. The postoperative VAS score was lower in Group CM than in Group NM (p = 0.045) in the 5^th minute. The postoperative additional analgesic requirements were lower in Groups PM and CM than in Group NM (p = 0.045). The postoperative blood glutathione peroxidase values were significantly higher in Groups PM and CM than in Group NM (p = 0.001). The postoperative catalase values were significantly higher in Groups PM and CM than in Group NM (p = 0.008 and p ≤ 0.001). The preoperative malondialdehyde values were significantly lower in Groups PM and CM than in Group NM. The preoperative nitric oxide values were higher in Groups PM and CM than in Group NM (p ≤ 0.001), whereas the postoperative nitric oxide values were lower in Groups PM and CM than in Group NM (p ≤ 0.001).ConclusionTurkish classical music has beneficial effects on pain and oxidative stress in oocyte pick‐up patients.     

Efeitos de dexmedetomidina em conjunto com o pré‐condicionamento isquêmico remoto em lesão de isquemia‐reperfusão renal em ratos

Background and objectivesThe aim of this study was to evaluate the effects of remote ischemic preconditioning by brief ischemia of unilateral hind limb when combined with dexmedetomidine on renal ischemia–reperfusion injury by histopathology and active caspase‐3 immunoreactivity in rats.Methods28 Wistar albino male rats were divided into 4 groups. Group I (Sham, n = 7): Laparotomy and renal pedicle dissection were performed at 65th minute of anesthesia and the rats were observed under anesthesia for 130 min. Group II (ischemia–reperfusion, n = 7): At 65th minute of anesthesia bilateral renal pedicles were clamped. After 60 min ischemia 24 h of reperfusion was performed. Group III (ischemia–reperfusion + dexmedetomidine, n = 7): At the fifth minute of reperfusion (100 μg/kg intra‐peritoneal) dexmedetomidine was administered with ischemia–reperfusion group. Reperfusion lasted 24 h. Group IV (ischemia–reperfusion + remote ischemic preconditioning + dexmedetomidine, n = 7): After laparotomy, three cycles of ischemic preconditioning (10 min ischemia and 10 min reperfusion) were applied to the left hind limb and after 5 min with group III.ResultsHistopathological injury scores and active caspase‐3 immunoreactivity were significantly lower in the Sham group compared to the other groups. Histopathological injury scores in groups III and IV were significantly lower than group II (p = 0.03 and p = 0.05). Active caspase‐3 immunoreactivity was significantly lower in the group IV than group II (p = 0.01) and there was no significant difference between group II and group III (p = 0.06).ConclusionsPharmacologic conditioning with dexmedetomidine and remote ischemic preconditioning when combined with dexmedetomidine significantly decreases renal ischemia–reperfusion injury histomorphologically. Combined use of two methods prevents apoptosis via active caspase‐3.     

Extraluminal helicoidal stretch (Helixtretch): A novel method of intestinal lengthening

PurposeWe sought to test a novel, extraluminal method of intestinal lengthening that precludes violation of the intestinal wall.MethodsSprague–Dawley rats (n = 45) with size-matched bowel segments isolated by Roux-en-Y reconstruction were divided into three groups. Group 1 (n = 14) had no further manipulations. In Groups 2 (n = 12) and 3 (n = 19), the isolated segment was wrapped around a length-matched device in a helicoidal fashion. In Group 2, the device consisted of plain polyurethane tubing. In Group 3, it consisted of a gradually expanding hygroscopic hydrogel (12.5 mm final diameter). Euthanasia was performed at 8–21 days. Statistical analysis was by two-way ANOVA (P < 0.05).ResultsOverall survival was 87% (39/45). There was a statistically significant increase in bowel length in Group 3 compared to the other two groups (P < 0.001). This increase correlated with the number of helicoidal coils (P = 0.018), but not with post-operative time (P > 0.50). There were no significant differences in total DNA/protein ratio across the groups (P = 0.65). Histologically, there was an apparent increase in the goblet cell density in Group 3.ConclusionsMeasured extraluminal helicoidal stretch (Helixtretch) is tolerated by the intestine. Helixtretch induces bowel lengthening in a rodent model. Further analysis of this novel, minimally invasive alternative for intestinal augmentation is warranted.     

Sugammadex versus neostigmina em pacientes pediátricos: estudo prospectivo e randomizado

Background and objectivesAcetylcholinesterase inhibitors may cause postoperative residual curarization when they are used for reversal of neuromuscular blockade. Sugammadex reverses neuromuscular blockade by chemical encapsulation and is not associated with the side effects that may occur with the use of anticholinesterase agents. Because of increased outpatient surgical procedures postoperative residual curarization and rapid postoperative recovery have a greater importance in the pediatric patient population. The aim of this study was to compare the efficacy of sugammadex and neostigmine on reversing neuromuscular blockade in pediatric patients undergoing outpatient surgical procedures.Methods80 patients, aged 2–12 years, scheduled for outpatient surgery were enrolled in this randomized prospective study. Neuromuscular blockade was achieved with 0.6 mg kg⁻¹ rocuronium and monitorized with train‐of‐four. Group RN (n = 40) received 0.03 mg kg⁻¹ neostigmine, Group RS (n = 40) received 2 mg kg⁻¹ sugammadex for reversal of rocuronium. Extubation time (time from the reversal of neuromuscular blockade to extubation), train‐of‐four ratio during this time, time to reach train‐of‐four > 0.9, and probable complications were recorded.ResultsThere was no significant difference between the patients’ characteristics. Extubation time and time to reach train‐of‐four > 0.9 were significantly higher in Group RN (p = 0.001, p = 0.002). Train‐of‐four at the time of neostigmine/sugammadex injection in Group RN were significantly higher than in the RS group (p = 0.020). Extubation train‐of‐four ratio was significantly lower in Group RN (p = 0.002).ConclusionSugammadex provides safer extubation with a shorter recovery time than neostigmine in pediatric patients undergoing outpatient surgical procedures.     

The contribution of periapical nerve block in transrectal ultrasound-guided prostate biopsy: Results from a prospective randomized trial

ObjectivePeriprostatic nerve block has been shown to be the most effective method to reduce pain during transrectal ultrasound (TRUS) guided prostate biopsy, but the ideal technique remains controversial. The aim of this study was to compare pain control between bilateral basal block (BBB) alone and BBB combined with periapical nerve block (PNB).Patients and methodsFrom November 2007 to May 2009, 182 consecutive patients with abnormally elevated serum prostate-specific antigen (PSA) or suspicious digital rectal examination (DRE) underwent TRUS-guided needle biopsy of the prostate. The patients were prospectively randomized after informed consent had been obtained. Group 1 (n = 90) underwent bilateral basal block (BBB) with periprostatic infiltration of 8 ml 1% lidocaine into the neurovascular bundle at the prostate-seminal vesicle junction on each side. Group 2 (n = 92) underwent BBB with the addition of periapical nerve block (PNB) using 2 ml 1% lidocaine per side. A visual analog scale (VAS) was used to evaluate the patient's perception of pain during the biopsy.ResultsThe mean patient age was 64.6 ± 8.2 years and the average VAS was 1.9 ± 2.0. The mean VAS was lower in Group 2 compared with Group 1, 1.6 ± 1.9 versus 2.2 ± 2.0 (p = 0.026). In the subgroup aged 56–65 years the mean VAS was 1.26 ± 0.6 in Group 1 versus 2.46 ± 0.5 in Group 2 (p = 0.001), and in the subgroup aged 66–87 years it was 1.41 ± 0.5 in Group 1 versus 1.66 ± 0.75 in Group 2 (p = 0.554).ConclusionsBBB combined with PNB seems to be more effective to BBB alone to reduce pain during TRUS-guided prostate biopsy and may be of maximum benefit for younger patients.     

Gaining Consent for Carotid Surgery: A Simulation-Based Study of Vascular Surgeons

AimDespite no formal training in consenting patients, surgeons are assumed to be competent if they are able to perform an operation. We tested this assumption for carotid endarterectomy (CEA).MethodsThirty-two surgeons [Group 1: junior surgical trainees – performed 0 CEA's (n = 11); 2: senior vascular trainees – 1–50 CEA's (n = 11); 3: consultant vascular surgeons – > 50 CEA's (n = 10)] consented two patients (trained actors) for a local anaesthetic CEA. The performance was assessed at post hoc video review by two independent assessors using a validated rating scale and checklist of risk factors.ResultsThere was no difference in performance between the junior and senior trainees (1: median 91 range 64–121; 2: median 100.5 range 66–125; p = 0.118 1 vs. 2 Mann–Whitney). There was a significant improvement between senior trainees and consultant surgeons (3: median 120 range 89–1 142; p = 0.001 2 vs. 3). Few junior (1/11) and senior (2/11) trainees, and most (8/11) consultants, were competent. Inter-rater reliability was high (α = 0.832).Consultant surgeons were significantly more likely to discuss cranial nerve injuries (p < 0.0001 Chi-square test) as well as personal or hospital specific stroke risk (p < 0.0001) than their junior counterparts. They were less likely to discuss infection (p < 0.0001).ConclusionSenior trainees, despite being able to perform a CEA, were not competent in consent. The majority of consultant surgeons had developed competence in consenting even though they had no formal training.     

Clonidine versus fentanyl as adjuvants to bupivacaine in peribulbar anesthesia

BackgroundPeribulbar anesthesia is widely practiced as a safe local block for cataract eye surgeries. Fentanyl has been used as an adjuvant to local anesthetics, prolonging their duration of action. Clonidine has been shown to increase the duration of analgesia and anesthesia produced by local anesthetics.Aim of the studyThe aim of this study was to compare the effect of fentanyl versus that of clonidine when used as adjuvants to bupivacaine in peribulbar block.MethodologyNinety patients, ASA physical status I–III, scheduled for cataract operations, under peribulbar block, were enrolled in the study and randomly assigned into 3 equal groups. Group F (n = 30) received a mixture of bupivacaine, hyaluronidase, and fentanyl; Group C (n = 30) received a mixture of bupivacaine, hyaluronidase, and clonidine; and in the control Group B (n = 30), a mixture of bupivacaine, hyaluronidase, and saline was used for peribulbar block. The onset, duration of globe anesthesia, akinesia, and lid akinesia were recorded. Intraoperative and postoperative patient comfort, first time to analgesic request, and any recorded complications due to drugs used were all assessed.ResultsGroups C and F showed significantly faster onset and longer duration of globe anesthesia, akinesia, lid akinesia, and the time to first analgesic request when compared to Group B (p < 0.001). The onset, of lid akinesia was significantly faster in Group C compared to Group B (p < 0.01). Group C showed a significantly longer duration of lid akinesia and globe akinesia compared to Group F (p < 0.01).ConclusionThe addition of either clonidine or fentanyl to the local anesthetic during peribulbar block results in a faster onset and longer duration of the block with a longer period of postoperative analgesia. The addition of clonidine was found to prolong the duration of the block more than fentanyl.     

Endovascular Repair of the Thoracic Aorta: Predictors of 30-Day Mortality in Patients on the New Zealand Thoracic Aortic Stent Database (NZ TAS)

ObjectivesTo evaluate data in the New Zealand Thoracic Aortic Stent database to try and identify a scoring system that could predict 30-day mortality in patients undergoing stenting of the descending thoracic aorta (TEVAR).DesignRetrospective analysis of the New Zealand thoracic aortic stent database between December 2001 and August 2007.Materials and methodsThe 30-day mortality of the 122 patients is 7.38% (n = 9). Risk factors were recorded based on the Society of Thoracic Surgeons (STS) risk score. Glasgow aneurysm score was calculated and the pathology being treated analysed. Univariate analyisis was carried out.ResultsThe mortality of three pathology groups was compared. 30-day mortality was 2.04% (n = 1) in the elective aneurysm group, 17.95% (n = 7) in the complicated Stanford type B dissection group, and 0% (n = 0) in the trauma group. Thirty-day mortality is significantly higher in the dissection group compared with the elective aneurysm (p = 0.02) and trauma (p = 0.03) groups. The most frequent risk factors in the dissection group of patients were peripheral vascular disease, smoking and hypertension. Although percentage mortality is higher with increasing GAS, the results are not statistically significant (p = 0.34). No independent risk factors were identified from the STS risk score data.ConclusionNo specific risk score system seems to be able to predict mortality in TEVAR patients.     

Arthroscopic ankle arthrodesis: Are results reproducible irrespective of pre-operative deformity?

BackgroundArthroscopic ankle arthrodesis is gaining in popularity. It has been shown to have a shorter time to union and less morbidity than traditional open procedures. The arthroscopic technique has been mainly used for ankles with minimal deformity. Our aim was to find out whether we could reproduce the good results of arthroscopic ankle arthrodesis in both minimally and markedly deformed ankles.MethodsWe reviewed 62 patients who underwent an arthroscopic ankle arthrodesis for end stage arthritis. The average follow up was 63 months (range 21–92 months). Patients were evaluated subjectively and objectively using the Mazur grading system. 4 patients died before final review and 3 were lost to follow-up leaving 55 patients for evaluation.The pre-operative tibiotalar angle in the coronal plane was between 26° valgus and 24° varus. We divided our patients into 2 groups based on the tibiotalar angle. Group A (n = 31) had a varus or valgus deformity of less than 15? and Group B (n = 24) had a deformity equal to or more than 15°.ResultsThe overall fusion rate was 91%. Fusion occurred in 29 of 31 (94%) ankles in Group A compared to 21 of 24 (88%) in Group B (p = 0.64).The overall mean time to union was 10.4 weeks. The time to union in Group A was 8.8 weeks compared to 12.7 weeks for Group B (p = 0.001). Using the Mazur ankle grading system, 84% of the cases in Group A had a good to excellent result compared to 79% in Group B (p = 0.73). There were 2 superficial infections, 2 cases of deep vein thrombosis and 3 patients required removal of prominent screws.ConclusionsWe have shown that arthroscopic ankle arthrodesis yields reliable and reproducible results in a District General Hospital setting with high union rates, short time to union and low complication rates. It can be satisfactorily employed for ankles with significant deformity, although this resulted in a longer time to union. The end results remain uniformly good to excellent.     

Assessment of calcific tendonitis of rotator cuff by ultrasonography: Comparison between symptomatic and asymptomatic shoulders

ObjectiveCalcific tendonitis of rotator cuff is observed on plain radiographs in 10% of adults, but remains asymptomatic in half these cases. We looked for differences on ultrasound (US) and power Doppler findings between symptomatic and asymptomatic cases of shoulder calcific tendonitis.MethodsUS was performed in 62 patients (81 shoulders) with symptomatic (n = 57) or asymptomatic (n = 24) calcific tendonitis. Calcific plaque morphology, power Doppler signaling, and widening of the subacromial-subdeltoid bursa (SSB) were recorded. US-guided steroid injection into the SSB (n = 21) or needle puncture of calcific deposits (n = 29) was performed at the end of US evaluation in 50 of the 57 patients, and a questionnaire was sent to each patient after 11 ± 6 months.ResultsLarger (p = 0.0015) and fragmented (p = 0.01) calcifications were associated with pain. A power Doppler signal and a widening of the SSB was identified in 21 and 17 of the 57 symptomatic calcification respectively, but in none of the cases of asymptomatic calcification (p < 0,005). At least one of these signs was present in 31 of the 57 (54%) symptomatic shoulders (p < 0.001). Long-term outcome was favourable for 60% of our patients after steroid injection. The presence of a SSB widening before bursal steroid injection was associated with an improvement of the symptoms (p = 0.06).ConclusionPositive power Doppler signal within the calcific deposit and SSB widening are US features strongly associated with pain. Moreover, larger calcifications are also more symptomatic. According to these results, US can help physicians to confirm that calcification is responsible for shoulder pain.     

Role of Computed tomography in predicting prognosis of Hepatic portal venous gas

BackgroundThe aim of this study was to report through 13 cases the particularities of abdominal computed tomography (CT) aspects of hepatic portal venous gas (HPVG) and its correlation with patient prognosis.MethodsWe analyzed abundance of HPVG and its association with pneumatosis intestinalis (PI) in correlation with fatal outcome using chi-square tests.ResultsEtiologies were mesenteric infarction (n = 5), sigmoid diverticulitis (n =  1), septic shock (n = 1), postoperative peritonitis (n = 1), acute pancreatitis (n = 1), iatrogenic cause (n = 3) and idiopathic after a laparotomy (n = 1). The outcome was fatal in for 6 patients. Abundance of HPV was expressed in total number of hepatic segments involved. The involvement of 3 or more segments was a sensitive sign for lethal outcome with high sensitivity (100%) but it was not specific (50%). Negative predictive value of this sign was 100% (p ≤ 0.005). Positive predictive value of PI for death was 100% (p ≤ 0.001).DiscussionAbundance of HPVG is correlated with prognosis. The presence of PI announces poor outcome Negative predictive value of presence of HPVG in 3 or more segments is interesting. Predicting prognosis with CT can help surgeons to assess the most adequate treatment. Iatrogenic causes are increasingly described after interventional radiology procedures with favorable course.ConclusionThe first etiology radiologists should look for in front of HPVG involving more than 3 hepatic segments and associated with PI is intestinal necrosis which announces a poor prognosis. This study shows that outside of shock situations, HPVG involving 2 or less hepatic segments without PI predicts a good outcome.     

An observational study of plasma vascular endothelial growth factors (VEGF) A and D expression in non-localized prostate cancer

BackgroundThe aim of the study was to measure plasma levels of the vascular endothelial growth factors (VEGF) A and D in serially collected blood specimens from non-localized prostate cancer (PCa) subjects.MethodsPlasma VEGF A and D levels were measured in two serial specimens 3–6 months apart in two groups of non-localized stage PCa patients. Group 1 was comprised of patients with biochemical relapse after localized PCa treatments and/or patients with clinically metastatic hormone-sensitive stage PCa prior to receiving hormonal therapy. Group 2 included patients failing hormonal therapy for non-localized hormone-sensitive stage PCa. VEGF A and D levels were compared within each cancer group between the two time-points using the Wilcoxon Rank Sum test.ResultsAt the first time-point in Group 1 (n = 46), median VEGF-A and D levels were measured at 5.2 (pg/ml) (range = 0–97) and 319 (range = 172–780) (pg/ml). For Group 2 (n = 34) VEGF-A level was 9.6 pg/ml (range = 0–78) and VEGF-D level was 377 pg/ml (range = 243–989) for the first measurement. Median time-period for the serial second specimen was 189 days in Group 1 and 84 days in Group 2. At the second time-point, in Group 1, VEGF-A levels were 0.0 pg/ml (P = 0.0002) while VEGF-D increased to 349 pg/ml (P = 0.002). For Group 2 patients at the second time-point, median VEGF-A was 0.0 pg/ml (P = 1.0) and VEGF-D was measured at 442 pg/ml (P = 0.008).ConclusionsHigher plasma VEGF-D than VEGF-A expression in advanced PCa stages suggests a greater role for VEGF-D dependent lymph angiogenesis in advanced stage PCa, which needs further evaluation.     

The management of right iliac fossa pain – Is timing everything?

BackgroundRight iliac fossa (RIF) pain remains the commonest clinical dilemma encountered by general surgeons. We prospectively audited the management of acute RIF pain, examining the relationship between symptom duration, use of pre-operative radiological imaging and patient outcome.MethodsOver a six-month period, 302 patients, median age 18 years, 59% female, were admitted with RIF pain. Symptoms, clinical findings and laboratory results were documented. Patient management, timing of radiological investigations and operations, and outcome were recorded prospectively.ResultsNon-specific abdominal pain (26%), gynaecological (22%) and miscellaneous causes (14%) accounted for most admissions. Ultimately, 119 patients (39%) had appendicitis. Anorexia, tachycardia or rebound tenderness in the RIF significantly predicted a final diagnosis of appendicitis. Patients with perforated appendicitis (n = 29) had a longer duration of pre-hospital symptoms (median 50 h) compared to those with simple appendicitis (median 17 h) (p < 0.001). The use of pre-operative imaging resulted in an increased time to surgery but was not associated with increased post-operative morbidity or perforated appendicitis.ConclusionThe majority of patients presenting to hospital with RIF pain did not have appendicitis. Increased duration of pre-hospital symptoms was the main factor associated with perforated appendicitis. However, increased in-hospital time to theatre was not associated with perforated appendicitis or post-operative morbidity.     

Nephron-sparing management (distal ureterectomy with reimplantation of ureter) for carcinoma of distal ureter: A single-center experience

ObjectiveRadical nephroureterectomy with bladder-cuff excision has been the traditional treatment for upper tract urothelial carcinoma because of its high rate of recurrence. However, given the morbidity of nephrectomy and the risk of developing chronic kidney disease or dialysis-dependent renal failure, the nephron-sparing approach may be preferable in selected patients.Materials and methodsA total of 118 patients who received unilateral distal ureterectomy with reimplantation at a single center in Taiwan were included, using surgical code numbers, from March 2006 to December 2014. A total of 82 patients were excluded due to nonmalignancy and 17 due to concomitant bladder cancer. Finally, 19 patients with primary, solitary, unilateral ureter lesions and confirmed to have ureter malignancy (urothelial carcinoma, n = 18; squamous cell carcinoma, n = 1) were included.ResultsOf the 19 patients (13 males and 6 females) included, the mean age was 69.3 ± 10.7 years. Tumor pathological staging was Tis (n = 1), Ta (n = 3), T1 (n = 2), T2 (n = 6), and T3 (n = 5). Histopathology grading was low grade (n = 3) and high grade (n = 13). No local recurrence was noted; nine patients had bladder recurrence (47.4%), three had distant metastasis (15.8%), and two had progression and finally underwent radical nephroureterectomy (10.5%). The mean time to bladder recurrence was 12.4 months (3–24 months); the mean follow-up time was 28.1 months (1–90 months). The 5-year overall survival rate was 73.7% (14/19); four patients were lost to follow-up, and one patient expired. The mean 5-year progression-free survival was 67.74%. The mean preoperative creatinine level was 1.61 mg/dL, and at 12 months after operation it was 1.56 mg/dL (p = 0.95).ConclusionIn selected patients, distal ureterectomy with reimplantation, in our experience, is a feasible option for distal ureter tumor. Favorable postoperative outcomes with a low local recurrence rate, a low rate of progression to nephroureterectomy, and renal function preservation may prove the value of this modality and should be taken into consideration in suitable patients.